Silicon Valley Execs & Failure to Follow a Plan

Why do all manner of people succumb to the tyranny of the urgent and fail to make and follow a plan?

I have worked for a number of years in aviation. I have even been a helicopter crew chief and flown a helicopter as part of being a flight test engineer.

Aviation is one of the most scrutinized industries in existence. By the same token, semiconductors are one of the fastest moving industries, often with few written processes for the innovative part -- this is "tribal knowledge" on a grand scale. Few of the major players in the semiconductor industry have every process written and documented to the level of even a small company in a regulated industry. When executives from the semiconductor industry take on the added role of flying a corporate or private plane, interesting things tend to happen, occasionally with fatal results.

A corporate jet is, on average, about a quarter as safe as a scheduled airliner. A private small plane can be 1/40th as safe. Why is this? The leading cause of all air crashes is pilot error -- typically failure to be able to recall and execute the correct emergency procedure for any one of the myriad possible in-flight emergencies, or failure to follow and execute the proper procedure or pre-flight plan.

Having been a crew chief of a small helicopter, I can say that even experienced combat veteran pilots occasionally exhibit lapses in judgment. Things like checking the engine while refueling and then taking off without closing the engine door -- once again, failure to follow a pre-flight plan.

Silicon Valley executives make huge sums of money. However, no amount of money or influence over people will get one out of a bad situation when one does something like the following:

A Silicon Valley executive had become quite wealthy in the 1990s, gotten married, had a child, and gotten divorced. In the course of all this, she had obtained a pilot's license and a multi-engine turbine aircraft endorsement. At some point, this woman had decided to buy a house in a small city on the East Coast and commute via her private jet to Silicon Valley.

One snowy winter weekend night, an emergency came up in Silicon Valley. This executive threw every caution to the wind: Without even filing a flight plan, she and a companion fueled the plane and started to taxi in the near-blinding snow. They also did not bother to de-ice the aircraft. Due to the added weight of the snow and ice on the wings, the plane struck the trees about a quarter of a mile from the end of the runway after the takeoff. The end result was two totally unnecessary fatalities.

At a company at which I worked, one of my own technicians had a friend who -- without being endorsed for nighttime, multi-engine flight -- took another friend and two young ladies up for a night flight over the small city we all worked in. The plane hit the ground about a quarter of a mile short of the runway on landing. The result on this occasion was four fatalities and a crash site we could all see on a noontime walk at work. Very sobering.

With all these reminders of why caution is advised when performing critical safety work, why do all manner of people succumb to the tyranny of the urgent and fail to make and follow a plan? Is your semiconductor company ISO certified? Are any safety standards adhered to in designing safety critical products (IEC, FAA, CAA, FDA, SAE, etc.)?

I confess to having the same reaction to short distance moving: fasten the belt. It's really good muscle memory - and that's why I do it. I could drive two feet without the belt. But I DON'T want to mess up the HABIT and the muscle memory of putting the belt on EVERY SINGLE TIME I DRIVE. Easy to ignore can turn into "really easy to ignore, when the consequences happen to be high."

As to the tyranny of the urgent, it's the same thing as not taking the time a task actually requires. It gets us into trouble. The same thing happens in project management when the schedule becomes the end rather than the means; the master rather than the servant. And it irritates the heck out of most engineers :-)

I can't sit in a car without a seatbelt. I get incredibly uncomfortable. It's such a pattern that, even to move a foot or two in my driveway, I end up putting the belt on. My brain tells me I can't turn the engine on without a seatbelt.

There are times I sit down in a restaurant and look for the safety belt!

Well said Duane. I also did a bit of flying once - never got fully licenced - but came to much the same conclusions - it's not something to be done unless you have ALL your wits about you. While the two cases above are tragic, they both show total irresponsibility - not only did they go against the rules and beyond their abilities, but in both cases other people were involved as well. In the case of the lady executive, she thought her company could not do without her. Now it has to.....

It's a rule with my employer that before we do anything hazardous - climbing a radio tower or working in an electricity substation for example - we discuss the job and the hazards, and we have special forms (read: checklists) to fill out before we start work. The people who take this procedure seriously don't often get into trouble. Those who ignore it or just treat it as a tick-box exercise are the ones that come short, also fatally in some cases.

Being a licensed pilot (haven't flown in a very long time though) I think I can claim a bit of understanding on this subject. I think that in general, human judgment and awareness is simply not up to the task of something as complex and unforgiving as flight. I was lucky in not having any emergencies while flying, but did have a few cases where I let myself get closer to a bad spot than I would like.

It can sneak up on you in small increments. Certainly there are some arrogant pilots who simply think they're too good to get in an accident - statistics prove that they are not. But, I think most pilots want to fly safely. We just need more tools than we're born with.

In a car, a small lapse in judgment might cause you to swerve back into your lane. But, then the incident is over. Fate resets. In an airplane, fate doesn't always reset so quickly.

It may be a small error in judgment to consider flying while under pressure. It may be a small error in judgment to discount the weather. Another small error to skip the flight plan, and another to skip de-ice. Sadly, those errors keep adding up. Fate will only reset once back on the ground, alive or not.

That's why check lists, as you stated, are so incredibly important. And just having the checklist isn't enough. You need to rehearse it, and rehearse it again and again. You need to rehearse the checklists so many times that they become patterns burned into your brain. Then, when it's time for a checklist, you still don't rely on memory. You read the checklist and use the pattern as a backup.

I can't sit in a car without a seatbelt. I get incredibly uncomfortable. It's such a pattern that, even to move a foot or two in my driveway, I end up putting the belt on. My brain tells me I can't turn the engine on without a seatbelt. For life critical activities, you need to practice those checklists so often that your brain won't let you go without it. If you don't have the time or care to do so, you're gambling against the odds.